Locally advanced breast

cancer and its manageme

nt
PRITHIVIRAJ
FINAL YEAR MBBS
S1 UNIT
GOVT MEDICAL COLLEGE AND HOSPITAL,OMANDURAR ESTATE,CHENNAI -02
Introduction
• Those patient who shows the
gross skin involvement ,
pectoral muscles involvement
 chest wall involvement
they don't have metastasis
hence ,grouped under locally advanced breast carcin
oma(T3 and T4)
Aim
• Good locoregional control
• Attempt at cure by chemotherapy
Salient features of LABC
• ANY TUMOR more than 5 cm with or without skin a
nd chest wall involvement are included under LABC
• under TNM , any stage IIB and III can be included un
der LABC .isolated supraclavicular metastasis is also
in the stage III/LABC category
• Mastitis carcinomatosa is also included.
Types
• Operable LOBC (large operable breast cancer) (IIB a
nd III A) -
• ulceration ,
• limited skin edema,
• fixation to the pectoralis muscles and
• bulky axillary nodes
are grave signs but resection can be done
• Inoperable (III B) -
• Extensive breast skin oedema
• intercostal nodes
• arm oedema
• inflammatory breast cancer
• Tissue diagnosis is established by core biopsy
• Core biopsy tissue is also evaluated for ER,PR ,HER2
/neu status ,P53 overexpression
• Biological markers important because if positive ,N
ACT is offered in the first place.those who respond t
o NAC are subjected to mastectomy or BCS.
Neoadjuvant therapy in brea
st cancer
• The modality is used for treating locally advanced b
reast cancer wherein due to the advanced nature of
the disease in the breast and /or axillary, the surgeo
n is unable to operate upon the patient initially
• If growth becomes impalpable clinically after finishi
ng ALL rounds of chemotherapy ,it is called a compl
ete clinical response (cCR)
• If the resected specimen shows viable microscopic
disease in a patient with cCR ,it is termed Partial pa
thological response
• If no microscopic growth is seen in the resected spe
cimen, then it is termed complete pathological res
ponse.
Neoadjuvant chemotherapy
• Patient should have a good general condition to rec
eive chemotherapy
• Full course of chemotherapy should be complete w
hether or not the growth has completely resolved
• Patient who have recieved full course of neoadjuva
nt chemotherapy before surgery neeed not recieve
any more chemotherapy in the adjuvant setting
• However, patients who didn't recieve full course of
neoadjuvant chemotherapy before surgery should fi
nish their remaining cycles after surgery
• Anti -HER2 (tratuzumab) can be given along with in
the neoadjuvant setting till all courses of chemothe
rapies are over and should be continued in the adju
vant setting for a total duration of one year.
Advantages of neoadjuvant c
hemotherapy
• Downstages the tumor
• Increase chance of breast conservation
• Inoperable tumors may become operable
• Systemic treatment is started early
• Inhibits a potential postsurgical growth spurts
• Chemotherapy is delivered through an intact vascul
ature
Neoadjuvant hormonal therap
y
• Postmenopausal patients who are not fits to reciev
e systemic cytotoxic therapies should undergo a tria
l of this modality
• A prior risk assessment of the ER/PR status should b
e done to make sure that the tumor is hormone res
ponsive
• Tamoxifen, letrazole,anastrozole all can be used.
 Neoadjuvant radiotherapy
• Patients not responding to the above mentioned tre
atment may be given a trail of this modality
• Neoadjuvant therapy apart from making inoperable
tumors operable also act as prognostic marked
• Even in LABC,if the treatment response is favourab
le BREAST CONSERVATION is possible.
Radiotherapy after LABC
• Tumor size of more than 5 cm before neoadjuvant
chemotherapy
• Positive margins after mastectomy
• More than 4 axillary lymph nodes
• Lymphovascular invasion
• ER negative
• High grade tumor